Case Study #3: A 27-year-old woman complains of multiple small tender lumps in her right and left axillae. She explains that she has noticed that they seem to make “tunnels” and sometimes open and smell bad.
CC: Patient states, “I have multiple small lumps in my right and left axillae which seem to make tunnels and sometimes open and smell bad.”
HPI: 27-year-old woman complains of multiple small tender lumps in her right and left axillae. She explains that she has noticed that they seem to make “tunnels” and sometimes open and smell bad.
PMH: denies health problems
Family Hx: none provided
Social Hx: Do you follow a particular diet and exercise regimen? Do you smoke or drink alcohol? Are you currently taking any medications?
Review of Systems (ROS):
Constitutional/General – AAOx4, pleasant, dressed appropriately, good hygiene. Reports lumps in her right and left axillae which make tunnels and have a foul odor.
Ears, Nose, Mouth & Throat – denies blurred vision, hearing loss, ear pain, ringing in ears, or discharge. Denies a sore throat or hoarseness, difficulty swallowing, mouth sores, toothache, nosebleed, or nasal discharge.
Cardiac – denies chest pain, palpitations, orthopnea. Regular rhythm and rate. No murmur or gallop. No peripheral edema.
Respiratory – Thorax normal to percussion. Breath sounds equal/clear bilaterally.
GI – abdomen nondistended, soft, and nontender. No hepatosplenomegaly, mass, or herniation.
GU – denies dysuria or urinary frequency.
Musculoskeletal – denies joint pain, swelling, muscle pain, cramps, neck pain or stiffness, or changes in ROM.
Dermatologic – reports small lumps in right and left axillae which open and smell bad. Denies abnormal nail or hair growth.
Neurologic – A/Ox4, denies numbness, tingling, paresthesia, or memory loss. CN II-XII intact.
Psychiatric – appropriate mood and affect noted. Good judgement and insight. No suicidal ideation.
27-year-old female. Include vital signs, height, and weight. Patient’s appearance is defined in terms of posture, body movements, clothing, grooming, and hygiene. Level of consciousness, facial expression, speech, conversational speed, articulation, and word use are all examples of actions.
When did you first notice the lumps?
Do the lumps appear at a certain time during the month? Any pattern?
Do you notice any improvement or worsening of the lumps?
Do any family members have a presence or history of similar lumps?
Have you noticed any presence of lumps in the groin, buttocks, or other areas?
Have you recently changed or used new deodorant?
Have you previously seen a provider regarding these lumps?
Are you currently doing anything at home to treat them?
Working diagnosis: Hidradenitis suppurativa L73.2
(Mayo Clinic, 2021)
Hidradenitis suppurativa causes small and painful lumps that form under the skin, especially in areas that rub together like the armpits, groin, buttocks, and breasts, and can lead to tunnels under the skin (Mayo Clinic, 2021). According to a study by Guet-Revillet et al. (2014), Staphylococcus lugdunesis was cultured as the predominant isolate from hidradenitis suppurativa nodules. Signs and symptoms include blackheads, painful pea-sized lumps that persist for weeks or months, leaking bumps or sores that have foul-smelling pus, and tunnels that connect the lumps (Mayo Clinic, 2021). Pertinent positives include lumps under the arm that are tunneling, leaking, and releasing foul-smelling pus.
Differential diagnosis 1: Furunculosis, unspecified L02.92
Furunculosis is a deep infection of the hair follicle, usually caused by Staphylococcus aureus, which leads to abscess formation with presence of pus and necrotic tissue (Ibler & Kromann, 2014). Furuncles are red, swollen, and tender nodules in varying sizes and appear on the extremities, behind the ears, under breasts, and in the groin. Predisposing factors include positive family history, Staphylococcus carriage, friction, malnutrition, poor hygiene, anemia, diabetes, and HIV infection (Ibler & Kromann, 2014). Pertinent positives include tender lumps, while pertinent negatives include malnutrition, Staphylococcus carriage, and other infections.
Differential diagnosis 2: Epidermal cyst L72.0
Epidermal cysts are noncancerous, painless, small bumps underneath the skin which can appear anywhere but are more prominent on the face, neck, and trunk (Mayo Clinic, 2021). The cysts may exhibit thick, yellow, foul-smelling drainage, and may cause swelling and tenderness in the area if infected (Mayo Clinic, 2021). Pertinent positives include small bumps underneath the skin with foul-smelling drainage, while pertinent negatives include presence of lumps in face, neck, and trunk.
Lab tests: CBC, urine and blood glucose, culture swabs of the lesion pus, nasal swab for r/o aureus
CBC measures the number of specific WBC (eosinophils) in the body which increases when the body encounters a foreign particle and detects abnormalities that may be linked to infections (Cleveland Clinic, 2021). CBC will help exclude systemic infection or other internal disease.
Urine and blood glucose testing for underlying diabetes, as a risk factor for furunculosis is diabetes (Ibler & Kromann, 2014).
Culture swabs of skin cells and microbes from lesions can be used to analyze microbial characteristics and epigenetic analysis (Byrd et al., 2019).
Nasal swabs from both anterior nares will isolate S. aureus, which can cause skin infections such as boils, folliculitis, carbuncles, and abscesses (Ansar et al., 2016). Nasal swabs revealed S. aureus in 89-100% of recurrent and nonrecurrent furunculosis (Ibler & Kromann, 2014).
Surgical approaches: uncovering tunnels, punch debridement to remove a single inflamed bump, surgical removal to remove entire affected skin and may require skin graft, and incision and drainage for short-term pain relief (Mayo Clinic, 2021).
Discharge Instructions/Education: Avoid shaving and using deodorant, as it can irritate the skin. Avoid smoking. Wear loose-fitting clothing around the affected areas and avoid hot, humid conditions. Warm compresses, hydrotherapy, and warm bath with antibacterial soap may help with the infection. Exercise regularly, maintain a regular sleep pattern, losing weight (if overweight) may help, and maintain a stress-free environment (Shah, 2005). If antibiotics are prescribed, take them as directed and do not skip or discontinue doses.
Follow-up: 2-3 weeks or sooner for any worsening symptoms such as fever, pain, and increased number of nodules or lesions.
Oral acetaminophen, oral non-steroidal anti-inflammatory drugs (ibuprofen) can alleviate pain. If pain management is ineffective with those OTC agents, oral opiates can be considered.
If disease severity is moderate (multiple, recurrent nodules with moderate pain, abscesses with purulent drainage), antibiotic pills such as doxycycline, clindamycin, and rifampin may be prescribed. Steroid injections (triamcinolone) will also help reduce swelling and inflammation, hormone pills (Estrace) might help with mild hidradenitis suppurativa, and tumor necrosis factor (TNF) inhibitors (Humira) improve symptoms within weeks (Mayo Clinic, 2021).
Non-medicinal efforts: A painful lump can be treated at home with the application of a warm compress to the hidradenitis suppurativa for 10 minutes and/or by placing a warm tea bag on the area for 10 minutes (American Academy of Dermatology Association, 2021).
2. A 31-year old Black woman reports her breasts get swollen, hard, and lumpy at times and she has pain that comes and goes. She has heard that Black women have a high rate of breast cancer.
CC: Pt reports swollen, hard, and lumpy breasts with intermittent pain.
HPI: Pt is a 31 yr old African American female, who presents with swollen, hard, and lumpy breasts with intermittent pain.
PMH: (1) How long have you noticed this? (2) Can you describe the type of pain you are feeling? (3) Do you have a family history of breast cancer? (4) Do you have any history of long term use of estrogen and progestin therapy? – I would ask this because as stated in the text the Women’s Health Initiative (WHI) study established that the extended use of combined estrogen and progestin therapy led to the increased chances of developing breast cancer (Jarvis, 2016).
FH: (1) Does your mother or father have a history of breast cancer? (2) Do your siblings have a history of breast cancer?
Review of Systems (ROS):
General – No issues
Cardiac – Denies chest pain
Respiratory – No issues
Dermatologic – Axilla is hard, and lumpy breasts with intermittent pain.
GI – Denies nausea, vomiting, diarrhea and constipation
Musculoskeletal: Denies muscle/joint pain and/or weakness.
Psychiatric – No issues
Pt is a 31 yr. African American female. No other complaints.
BP – 125/81, HR – 95 bpm, RR – 16, Temp – 98.2F, O2 – 100%
Inspection – Breasts are symmetric. Skin is smooth with even color and no rash or lesions. Arm movement shows no dimpling or retractions. No nipple discharge and no lesions.
Palpation – Breast contour and consistency are firm and homogeneous. No masses or tenderness. No lymphadenopathy.
I would take pt’s vitals, height and weight, assess the pt’s appearance whether she is well kept or not, assess her tone and responses when she communicates, after washing hands and donning gloves I would conduct a focused assessment on her breasts and axilla, include blood law draws, and image diagnostics.
Differential Diagnosis – Mastalgia or Mastodynia (N64.4). One of the signs and symptoms of this is pain related to mammary glands (Stachs et al., 2019). Pertinent positive: swollen, hard, lumpy, intermittent pain. Pertinent negative: Denied chest pain, like intercostal neuralgia and pain from cardiac or vertebrogenic origins.
Working Diagnosis – Breast cancer (C79.81). Some of the signs and symptoms of breast cancer include lumps, pain, and swelling (What are the symptoms of breast cancer? 2021). Pertinent Positive: swollen, hard, lumpy, intermittent pain. Pertinent Negative: Denied nipple discharge, flakiness, or change in size or shape of breast.
Treatment plan –
The treatment plan would include genetic testing for BRCA1 and BRCA2. According to the text, women who inherit a modification on one or both of the BRCA1 or BRCA2 genes, have a notably higher risk of forming into breast or ovarian cancer. Current documentation shows proof that the pervasiveness of these mutations are basically similar (at 1% to 4%) among breast cancer patients of African, Asian, White, and Hispanic origin. Before the age of 45 years old, African-American women have an increased chance of dying from the disease at every age (Jarvis, 2016). The model utilized would be the Gail model which is used widely among healthcare professionals. The model would help to identify risk factors involve, which would include current age, age at menstruation, age at first live birth, and any family history of breast cancer in first-degree family members. It will assist in calculating a 5-year, 30-year, or a lifetime risk approximation for each individual (Jarvis, 2016).
Imaging would include mammography screening.
Follow up: 1 month.